PLWC Slide Deck Series:PLWC Slide Deck Series:

Understanding Breast CancerUnderstanding Breast Cancer

PresentPresentss

20062006

What is Cancer?

A group of 100 different diseases

The uncontrolled, abnormal growth of cells

Cancer may spread to other parts of the body

What is Breast Cancer?

The most common type of cancer in women in the United States (excluding cancers of the skin) and the second most frequent cause of death from cancer in women

A disease in which normal cells in the breast begin to change, grow without control, and no longer die

Cancer that has not spread is called in situ, meaning “in place”

Cancer that has spread is called invasive or infiltrating

What is the Structure of the Breast?The breast is composed mainly of fatty tissue, which contains a network of lobes made up of tiny, tube-like structures called lobules that contain milk glands

Tiny ducts connect the glands, lobules, and lobes, and carry the milk from the lobes to the nipple

Blood and lymph vessels run throughout the breast

About 90% of all breast cancers originate in the ducts or lobes of the breast

What Are the Risk FactorsWhat Are the Risk Factors for Breast Cancer? for Breast Cancer?

AgeAgeRaceRaceIndividual or family history of breast cancerIndividual or family history of breast cancerA history of ovarian cancerA history of ovarian cancerA genetic predisposition (mutations to the BRCA1 or A genetic predisposition (mutations to the BRCA1 or BRCA2 genes cause 2% to 3% of all breast cancers)BRCA2 genes cause 2% to 3% of all breast cancers)Estrogen exposureEstrogen exposureAtypical hyperplasia of the breastAtypical hyperplasia of the breastLobular carcinoma in situ (LCIS)Lobular carcinoma in situ (LCIS)Lifestyle factors (obesity, lack of exercise, alcohol use)Lifestyle factors (obesity, lack of exercise, alcohol use)RadiationRadiation

Hereditary Breast CancerAbout 15% of breast cancers are inheritedAbout 15% of breast cancers are inheritedApproximately 80% of hereditary breast cancer is caused Approximately 80% of hereditary breast cancer is caused by mutations in the BRCA1 or BRCA2 genesby mutations in the BRCA1 or BRCA2 genesWomen who inherit a BRCA mutation have a 50% to 85% Women who inherit a BRCA mutation have a 50% to 85% chance of developing breast cancer in their lifetimechance of developing breast cancer in their lifetimeWomen with especially strong family history may Women with especially strong family history may consider preventive surgery to remove breast tissue consider preventive surgery to remove breast tissue and/or chemopreventionand/or chemopreventionSeveral other genetic syndromes can increase breast Several other genetic syndromes can increase breast cancer riskcancer riskGenetic counseling and testing is available for most Genetic counseling and testing is available for most syndromessyndromesFor more information, www.plwc.org/geneticsFor more information, www.plwc.org/genetics

Breast Cancer and Early Detection

Early diagnosis means a better chance of Early diagnosis means a better chance of successful treatmentsuccessful treatment

Mammography is the best tool doctors have to Mammography is the best tool doctors have to screen for breast cancerscreen for breast cancer

Many organizations recommend that women obtain Many organizations recommend that women obtain a mammogram each year, starting at the age of 40a mammogram each year, starting at the age of 40

Regular clinical breast examinations and breast Regular clinical breast examinations and breast self-examinations are also recommendedself-examinations are also recommended

Women are encouraged to discuss the frequency of Women are encouraged to discuss the frequency of screening with their doctorsscreening with their doctors

What Are the Symptoms of Breast Cancer?What Are the Symptoms of Breast Cancer?New lumps or a thickening in the breast or under the armNew lumps or a thickening in the breast or under the arm

Nipple tenderness, discharge, or physical changesNipple tenderness, discharge, or physical changes

Skin irritation or changes, such as puckers, dimples, Skin irritation or changes, such as puckers, dimples, scaliness, or new creasesscaliness, or new creases

Warm, red, swollen breasts with a rash resembling the Warm, red, swollen breasts with a rash resembling the skin of an orangeskin of an orange

Pain in the breast (usually not a symptom of breast cancer, Pain in the breast (usually not a symptom of breast cancer, but should be reported to a doctor)but should be reported to a doctor)

No visible or obvious symptoms (asymptomatic)No visible or obvious symptoms (asymptomatic)

How is Breast Cancer Evaluated?How is Breast Cancer Evaluated?Screening and/or diagnostic mammographyScreening and/or diagnostic mammography

UltrasoundUltrasound

Magnetic Resonance imaging (MRI) scanMagnetic Resonance imaging (MRI) scan

Biopsy is necessary to confirm a diagnosisBiopsy is necessary to confirm a diagnosis

Blood tests are often used to determine if the cancer Blood tests are often used to determine if the cancer has spread outside the breasthas spread outside the breast

Additional tests may be used to determine stageAdditional tests may be used to determine stage

Breast Cancer StagingBreast Cancer Staging

Staging is a way of describing a cancer, such as Staging is a way of describing a cancer, such as the depth of the tumor and where it has spreadthe depth of the tumor and where it has spread

Staging is the most important tool doctors have to Staging is the most important tool doctors have to determine a patient’s prognosis determine a patient’s prognosis

Staging is described by the TNM system: the size Staging is described by the TNM system: the size of the of the TTumor, whether cancer has spread to umor, whether cancer has spread to nearby lymph nearby lymph NNodes, and whether the cancer has odes, and whether the cancer has MMetastasized (spread to organs such as the liver etastasized (spread to organs such as the liver or lungs)or lungs)

The type of treatment a person receives depends The type of treatment a person receives depends on the stage of the canceron the stage of the cancer

Stage Stage 00 Breast Cancer Breast Cancer

Known as “cancer in situ,” meaning the cancer Known as “cancer in situ,” meaning the cancer has not spread past the ducts or lobules of the has not spread past the ducts or lobules of the breast (the natural boundaries)breast (the natural boundaries)

Also called noninvasive cancerAlso called noninvasive cancer

Ductal carcinoma in situ (DCIS) is the most Ductal carcinoma in situ (DCIS) is the most common in situ breast cancercommon in situ breast cancer

Stage I Breast CancerStage I Breast Cancer

The tumor is small The tumor is small and has not spread to and has not spread to the lymph nodesthe lymph nodes

Stage IIa Breast CancerStage IIa Breast Cancer

Stage IIa breast cancer Stage IIa breast cancer describes a smaller describes a smaller tumor that has spread to tumor that has spread to the axillary lymph nodes the axillary lymph nodes (lymph nodes under the (lymph nodes under the arm), or a medium-sized arm), or a medium-sized tumor that has not tumor that has not spread to the axillary spread to the axillary lymph nodeslymph nodesStage IIa may also Stage IIa may also describe cancer in the describe cancer in the axillary lymph nodes with axillary lymph nodes with no evidence of a tumor in no evidence of a tumor in the breastthe breast

Stage IIb Breast CancerStage IIb Breast Cancer

Stage IIb breast cancer Stage IIb breast cancer describes a medium-describes a medium-sized tumor that has sized tumor that has spread to the axillary spread to the axillary lymph nodeslymph nodesStage IIb may also Stage IIb may also describe a larger tumor describe a larger tumor that has not spread to that has not spread to the axillary lymph nodesthe axillary lymph nodes

Stage IIIa Breast CancerStage IIIa Breast Cancer

Stage IIIa breast Stage IIIa breast cancer describes any cancer describes any size tumor that has size tumor that has spread to the lymph spread to the lymph nodesnodes

Stage IIIb Breast CancerStage IIIb Breast Cancer

Stage IIIb breast Stage IIIb breast cancer has spread to cancer has spread to the chest wall, or the chest wall, or caused swelling or caused swelling or ulceration of the ulceration of the breast, or is diagnosed breast, or is diagnosed as inflammatory breast as inflammatory breast cancercancer

Stage IIIc Breast CancerStage IIIc Breast Cancer

Stage IIIc breast Stage IIIc breast cancer has spread to cancer has spread to distant lymph nodes distant lymph nodes but has not spread but has not spread to distant parts of to distant parts of the bodythe body

Stage IV Breast CancerStage IV Breast Cancer

Stage IV breast cancer can be any size and Stage IV breast cancer can be any size and has spread to distant sites in the body, has spread to distant sites in the body, usually the bones, lungs or liver, or chest usually the bones, lungs or liver, or chest wallwall

How is Breast Cancer Treated?How is Breast Cancer Treated?Treatment depends on stage of cancerTreatment depends on stage of cancer

More than one treatment may be usedMore than one treatment may be used

SurgerySurgery

Radiation therapyRadiation therapy

ChemotherapyChemotherapy

Hormone therapyHormone therapy

Targeted therapyTargeted therapy

Factors Considered in Treatment Factors Considered in Treatment DecisionsDecisions

The stage and grade of the tumorThe stage and grade of the tumor

The tumor’s hormone receptor status (ER, PR)The tumor’s hormone receptor status (ER, PR)

Factors that may signify an aggressive tumor, such as Factors that may signify an aggressive tumor, such as HER-2/neu amplificationsHER-2/neu amplifications

The presence of known mutations to breast cancer genesThe presence of known mutations to breast cancer genes

The patient’s menopausal statusThe patient’s menopausal status

The patient’s age and general healthThe patient’s age and general health

Cancer Treatment: SurgeryCancer Treatment: Surgery

Generally, surgery to remove the tumor with or Generally, surgery to remove the tumor with or without radiation therapy is initial treatmentwithout radiation therapy is initial treatment

For invasive cancer, lymph nodes are removed For invasive cancer, lymph nodes are removed and evaluatedand evaluated

More invasive surgery (such as mastectomy) is More invasive surgery (such as mastectomy) is not always better; discuss with your doctornot always better; discuss with your doctor

Breast reconstruction is an option after Breast reconstruction is an option after mastectomymastectomy

Cancer Treatment: Adjuvant TherapyCancer Treatment: Adjuvant Therapy

Treatment given in addition to surgery to reduce Treatment given in addition to surgery to reduce the risk of recurrencethe risk of recurrence

May include radiation therapy, chemotherapy, May include radiation therapy, chemotherapy, biologic therapy, and hormone therapybiologic therapy, and hormone therapy

Cancer Treatment: Radiation TherapyCancer Treatment: Radiation TherapyThe use of high-energy x-rays or other particles to destroy The use of high-energy x-rays or other particles to destroy cancer cellscancer cells

Usually used to treat breast cancer after surgeryUsually used to treat breast cancer after surgery

Different methods of deliveryDifferent methods of delivery

External-beam: outside the bodyExternal-beam: outside the body

Internal: uses implants inside the bodyInternal: uses implants inside the body

Side effects may include fatigue, swelling, and skin changesSide effects may include fatigue, swelling, and skin changes

Cancer Treatment: ChemotherapyCancer Treatment: Chemotherapy

Drugs used to kill cancer cellsDrugs used to kill cancer cells

May be given before surgery to shrink a large May be given before surgery to shrink a large tumor (neoadjuvant chemotherapy) or after tumor (neoadjuvant chemotherapy) or after surgery to reduce the risk of recurrence surgery to reduce the risk of recurrence (adjuvant chemotherapy)(adjuvant chemotherapy)

A combination of medications is often usedA combination of medications is often used

Cancer Treatment: Hormone TherapyCancer Treatment: Hormone Therapy

Used to manage tumors that test positive for either Used to manage tumors that test positive for either estrogen or progesterone receptorsestrogen or progesterone receptors

May be used alone or together with chemotherapyMay be used alone or together with chemotherapy

Tamoxifen (Nolvadex) is a common hormone therapy Tamoxifen (Nolvadex) is a common hormone therapy and is effective in many premenopausal and and is effective in many premenopausal and postmenopausal womenpostmenopausal women

Aromatase inhibitors are also used alone or following Aromatase inhibitors are also used alone or following tamoxifen use as treatment for postmenopausal women, tamoxifen use as treatment for postmenopausal women, including anastrozole (Arimidex), letrozole (Femara), including anastrozole (Arimidex), letrozole (Femara), and exemestane (Aromasin)and exemestane (Aromasin)

New Therapies: Targeted TherapyNew Therapies: Targeted Therapy

Treatment designed to target cancer cells while Treatment designed to target cancer cells while minimizing damage to healthy cellsminimizing damage to healthy cells

Used to stop the action of abnormal proteins that cause Used to stop the action of abnormal proteins that cause cells to grow and divide out of controlcells to grow and divide out of control

Trastuzumab (Herceptin) for women with a HER-2/neu-Trastuzumab (Herceptin) for women with a HER-2/neu-positive breast cancer either with or after adjuvant positive breast cancer either with or after adjuvant chemotherapychemotherapy

Bevacizumab (Avastin) blocks angiogenesis (the Bevacizumab (Avastin) blocks angiogenesis (the formation of new blood vessels) and is under evaluation formation of new blood vessels) and is under evaluation in clinical trialsin clinical trials

The Role of Clinical Trials for the The Role of Clinical Trials for the Treatment of Breast CancerTreatment of Breast Cancer

Clinical trials are research studies involving peopleClinical trials are research studies involving people

They test new treatment and prevention methods They test new treatment and prevention methods to determine whether they are safe, effective, and to determine whether they are safe, effective, and better than the best known treatmentbetter than the best known treatment

The purpose of a clinical trial is to answer a The purpose of a clinical trial is to answer a specific medical question in a highly structured, specific medical question in a highly structured, controlled processcontrolled process

Clinical trials can evaluate methods of cancer Clinical trials can evaluate methods of cancer prevention, screening, diagnosis, treatment, and/or prevention, screening, diagnosis, treatment, and/or quality of lifequality of life

Clinical Trials: Patient SafetyClinical Trials: Patient Safety

Informed consent: Participants should Informed consent: Participants should understand why they are being offered entry into understand why they are being offered entry into a clinical trial and the potential benefits and risksa clinical trial and the potential benefits and risks

Informed consent is an ongoing process; Informed consent is an ongoing process; participants are constantly updated as new participants are constantly updated as new information becomes availableinformation becomes available

Participation is always voluntary, and patients Participation is always voluntary, and patients can leave the trial at any timecan leave the trial at any time

Clinical Trials: PhasesClinical Trials: Phases

Phase I trials determine safety and dose of a new Phase I trials determine safety and dose of a new treatment in a small group of peopletreatment in a small group of people

Phase II trials provide more detail about the Phase II trials provide more detail about the safety of the new treatment and determine how safety of the new treatment and determine how well it works for treating a given form of cancerwell it works for treating a given form of cancer

Phase III trials take a new treatment that has Phase III trials take a new treatment that has shown promising results when used to treat a shown promising results when used to treat a small number of patients with cancer and small number of patients with cancer and compare it with the current, standard treatment compare it with the current, standard treatment for that disease; phase III trials involve a large for that disease; phase III trials involve a large number of patientsnumber of patients

Clinical Trials ResourcesClinical Trials Resources

Coalition of Cancer Cooperative Groups Coalition of Cancer Cooperative Groups (www.CancerTrialsHelp.org)(www.CancerTrialsHelp.org)

CenterWatch (www.centerwatch.com)CenterWatch (www.centerwatch.com)

National Cancer Institute National Cancer Institute (www.cancer.gov/clinical_trials)(www.cancer.gov/clinical_trials)

Coping With the Side Effects of CancerCoping With the Side Effects of Cancerand its Treatmentand its Treatment

Side effects are treatable; talk with the doctor or nurseSide effects are treatable; talk with the doctor or nurse

Fatigue is a common, treatable side effectFatigue is a common, treatable side effect

Pain is treatable; non-narcotic pain relievers are availablePain is treatable; non-narcotic pain relievers are available

Antiemetic drugs can reduce or prevent nausea and Antiemetic drugs can reduce or prevent nausea and vomitingvomiting

Lymphedema following breast cancer surgery can often be Lymphedema following breast cancer surgery can often be managed with help from your doctormanaged with help from your doctor

For more information, visit www.plwc.org/sideeffectsFor more information, visit www.plwc.org/sideeffects

Follow-Up CareFollow-Up Care

Important to detect possible recurrence at the earliest stageImportant to detect possible recurrence at the earliest stage

Monthly breast self-examinationsMonthly breast self-examinations

Physical examinationsPhysical examinations

MammogramsMammograms

Pelvic examinationsPelvic examinations

More information can be found in the More information can be found in the ASCO Patient Guide: ASCO Patient Guide: Follow-Up Care for Breast CancerFollow-Up Care for Breast Cancer

Where to Find More Information: PLWC Guide to Breast Cancer

(www.plwc.org/breast)

OverviewOverview

Medical IllustrationsMedical Illustrations

Risk Factors Risk Factors

PreventionPrevention

SymptomsSymptoms

DiagnosisDiagnosis

Staging With Staging With IllustrationsIllustrations

TreatmentTreatment

Side Effects of Cancer Side Effects of Cancer and Cancer Treatmentand Cancer Treatment

Questions to Ask the Questions to Ask the Doctor Doctor

Current ResearchCurrent Research

Patient Information Patient Information ResourcesResources

Clinical Trials Clinical Trials ResourcesResources

People Living With Cancer People Living With Cancer (www.plwc.org)(www.plwc.org)

PLWC is the cornerstone of ASCO’s patient resources PLWC is the cornerstone of ASCO’s patient resources programprogram

Visitors to PLWC will find:Visitors to PLWC will find: PLWC Guides to more than 90 types of cancerPLWC Guides to more than 90 types of cancer Coping resourcesCoping resources Ask the ASCO Expert Series, including chats, Q&A Ask the ASCO Expert Series, including chats, Q&A

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For patient information resources, please call 888-651-For patient information resources, please call 888-651-30383038